Rule out medical causes of the symptoms, especially thyroid and other endocrine diseases, or effects of medications (such as steroids, contraceptives, psychoactive substances).

Most depressive disorders can be treated by either medication or psychotherapy or both in combination. Patient preference is important.

Inform patients that initial side effects often pass within a week or so and that further dose increases and at least 4-8 weeks may be required to achieve a good medication trial. Using too low of a dose or too short of a trial are common reasons for a poor response to medication. Try to raise the dose to at least moderate levels for at least 4 weeks.

If the patient does not respond to or tolerate the first antidepressant that is tried, it is worth trying another before referring for specialty care. It is sometimes desirable to try a second medication from another class of antidepressants, unless co-morbid anxiety is prominent, in which case a second trial of an SSRI may be best.

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